Provider Demographics
NPI:1861031510
Name:WITTE, BRISTOL AUBURN (LMT, CCH)
Entity Type:Individual
Prefix:
First Name:BRISTOL
Middle Name:AUBURN
Last Name:WITTE
Suffix:
Gender:F
Credentials:LMT, CCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6457 FLUTTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9720
Mailing Address - Country:US
Mailing Address - Phone:260-704-2323
Mailing Address - Fax:
Practice Address - Street 1:3215 N ANTHONY BLVD STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-2259
Practice Address - Country:US
Practice Address - Phone:260-704-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21806580225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist